This morning, the leadership cadre of the NHS assemble in Liverpool for their annual stocktake at the NHS Confederation conference. Over the past week some of the key players in the system have been busy setting the conference agenda.

David Bennett kicked off on Friday when he set out Monitor’s new and tighter cost-control regime for foundation trusts. On Sunday, Simon Stevens took to the Marr sofa to call for a ‘clampdown’ on temporary staff agencies that were ‘ripping off’ the NHS. Yesterday morning, Jeremy Hunt responded to his chief executive’s call with new measures to contain ‘extortionate’ agency costs: a cap on hourly rates, a cap on agency spend for struggling trusts and a ban on using agencies that have not been approved.  

In a context where difficult choices abound, agency spend is a relatively easy but nonetheless sensible place to start. Whilst there will be continued debate about whether £8bn of additional funding and £22bn of efficiencies are the right numbers for the next five years, few will disagree that spending more than £3.3bn on temporary staff is money poorly spent if more cost-effective alternatives are available.

The run up to the Francis inquiry and its aftermath rebalanced system priorities towards safer staffing at a pace which made it hard for some trusts to avoid significantly increased agency spend. With continuing challenges on nurse recruitment both nationally and locally, the NHS now needs to find more sustainable ways of providing safe care.

Restrictions on agency staffing will need to be applied with sensitivity if they are not to be honoured in the breach. In acute hospitals at least, the wriggle room for staffing at, or below, the margins of safe care is now rightly much reduced. Ward level transparency on a monthly basis leaves understaffed wards exposed and a more vigilant inspectorate is now on the case and ready to cry foul. It is a reality of busy wards that staff will call in sick and the bank won’t always be able to cover. If patients need care, agency staffing will need to remain a last resort, particularly in parts of the country where recruitment of permanent staff is a challenge.

Given this emphasis on safe staffing and addressing the challenges of the current financial year, acute hospitals (and the NHS more widely in primary, community and mental health) must now think hard, and fairly quickly, about how to provide care safely with more efficient use of staff.

In the future, that will mean different types of health professionals, different skill mixes, and a sustained and focused investment in improvement to support NHS professionals and managers in the hard task of streamlining and standardising care where it makes sense to do so.

It will mean learning from best employment practice in the NHS and elsewhere so that shift patterns are able to flex to the parenting and caring responsibilities of the workforce, making it as easy to be an employee as it is to be a temp.

Employers will also need to look hard at morale, work pressures and culture on the wards to ensure that the control over one’s own work offered by temporary employment is not preferable to the stability of full time shifts on Agenda for Change terms.

For now, as a leadership signal to a system facing five tough years (and more to come beyond that), tackling agency spend should be totemic – not just because it saves money, but because it points to a choice about how the NHS should face austerity. In his first major speech on the NHS David Cameron said ‘there is no choice between efficiency savings and quality of care’, ruling out simple trade-offs. High levels of agency staffing is a case in point and should ring alarm bells, whether you are a patient or taxpayer.  

Whilst agency nurses and medical locums will generally arrive for a shift highly skilled and well-motivated, some of the key ingredients of really good care may be absent – an appreciation of the strengths and weaknesses of the team they are joining, an understanding of the particular routines, informal workarounds and clinical processes of the ward, and a sense of allegiance to the work of the organisation and its patients. It takes time for good professionals to be inducted into a team and to learn to function safely and efficiently in a new environment. An itinerant and intermittent workforce makes mistakes, gaps or duplication more likely. In this context, safe and efficient care go hand-in-hand.

I'm delighted that the Health Foundation has given me the opportunity to lead a programme of work to explore workforce issues like these in greater depth. Over the next two years I'll be trying to develop a better understanding of what makes staff tick and, in light of that, how different blends of national and local policy can support staff in meeting the big challenges the NHS faces.

As delegates debate in Merseyside bars and breakfast meetings, there is likely to be support for measures which will clearly help in facing the financial and quality challenge. Conversation will then turn to the rest of the £22bn, where the task of driving further improvements to quality and efficiency will be harder. That the leaders of the NHS are continuing to send signals on both of these goals this week is a good thing. There is now much more work to be done on how the centre and the front line can work together to create the right conditions for squaring this circle.

Gavin is a Policy Associate at the Health Foundation,


Linda Jane McLean

Great post, Gavin.

I believe that the action is decades too late
I understand that you are looking at the big picture, but sometimes an insight into the injustices felt on the ground can be helpful.

In Edinburgh in the 1980's, less than 10 per cent of the nurses trained were retained by the training hospital. The drive was for University Nurses.

This was folly in the highest degree.

Those "discarded" by the hospital, went to become Agency Nurses -and returned to work beside their colleagues for twice times the salary an NHS Nurse would expect.

The signal was given out loud and clear: do your training, and work as an Agency Nurse for REAL money. It was galling for the chosen Nurses to see those who had trained beside them, and rejected for a position, take home so much more pay, Moreover, it destroyed teamwork, as I knew it.

How did I feel? Incensed at the short -termism. Furious to see the NHS throw away so much talent: so many years of training on a false economy. It effectively removed the soul from Nursing. (Soulectomy?) But I had no voice.

Money is now what talks, which is the exact opposite of the ethos. And if you have money at the centre, how can we put the patient at the centre of care?.

The NHS was guilty of the most astounding mismanagement, false economies, and fiscal imprudence.It changed the culture, and it is debatable if this can ever be restored..

I wish you well in your endeavours.

felicite kamga

This is a situation NHS management should done a long time ago , I don't really understand how the NHS should pay more agency staff than NHS permanent staff , is time to increase the pay for permanent staff and use less agency staff, we are doing the same job, this was a madness for NHS management, and politicians should stay away for hospital management because I don't what can of job they are doing in House of Lords in London

Helen Igbinosa

I quite agree with the previous speakers, that it is money that talks. The same jobs are being done but different hourly pay ,Is that fair ? NO! NHS treats their own staff with ignominy while agency staff get paid double or even triple . Most of these politicians and their friends own these agencies and that is why these agencies are thriving with the nhs. You can imagine being taken from band 3 to band 2 and the job role remains the same, even more. All you can do is to change for a better pay somewhere else . Meetings upon meetings will not solve the problems until the wrongs in the pay structures are made right. PERIOD.

Comfort Oyede

Reducing agency staff in the National Health Service should have been targeted. It is a fact that some of the nursing agency fees were high; it was a gap created due to variance in need and available workforce an opportunity that was well utilised by agencies concerned. Most trusts struggling with staff shortage have no choice and this was exploited by the same staff as some reduce their hours to work on the bank. The agencies compound issues by inflating cost with their additional fees. I do not believe total elimination of agency staff engagement is the solution.
There need to be understanding of rationale behind low retention of staff; this is the main reason that underpins increase in agency usage. Pressure built up on existing staff, forced to do more work for same level of wage. Some fall ill and others reduce normal working hours (go part-time) creating a gap that needs filing to maintain full patient care. It is also possible that there are trusts with no retention issue but staff preferred to work as agency staff for financial reasons. Scenarios like this need addressed as blanket approach of disengagement of agency staff affects trust that have retention issues and this dovetails patient care.
Corporate departments are also affected as they struggle to maintain high level service. Some trust rely on agencies or private organisations to provide high level skilled workforce e.g. in IT based on necessity not on choice.
It is hoped that this policy will be looked into critically as I believe it is obstructing efficient care. A balance should be struck to reduce maximum impact on efficiency management and patient care.

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